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3. genetics

DOB / SSN
Periodic Fever Syndrome Panel
CUSTOMER INFORMATION
FIRST NAME
LAST NAME
ORGANIZATION
VAT NUMBER
BILLING ADDRESS 1ST LINE
BILLING ADDRESS 2ND LINE
POST CODE
CITY
EMAIL (Required)
COUNTRY
PHONE (Important for possible case discussion)
ADDRESS FOR TEST RESULTS (If an additional paper print-out of the results is ordered)
FIRST NAME
LAST NAME
ORGANIZATION
MAILING ADDRESS
POST CODE
CITY
COUNTRY
PATIENT INFORMATION
PATIENT NAME
AGE
PATIENT SSN / DOB
GENDER
ETHNICITY
1/6
DOB / SSN
CLINICAL HISTORY
SUSPECTED TYPE OF PERIODIC FEVER
FAMILIAL MEDITERRANEAN FEVER
TRAPS
HIDS
NOMID/CINCA
MUCKLE-WELLS SYNDROME
FCAS
PAPA SYNDROME
MAJEED SYNDROME
CYCLIC NEUTROPENIA
SEVERE CONGENITAL NEUTROPENIA
OTHER / SPECIFY
AFFECTED FAMILY MEMBERS
NO
YES / SPECIFY
OTHER RELEVANT FAMILY HISTORY
PREVIOUS GENETIC TESTS
NO
YES / SPECIFY TESTS AND RESULTS
PERIODIC FEVER
AVERAGE FEVER DURING ATTACK
38-39˚C
39-40˚C
> 40˚C
TOTAL NUMBER OF UNEXPLAINED ATTACKS
<3
4-6
7-10
> 10
ATTACK FREQUENCY
ATTACK DURATION
DAYS
DAYS
AGE AT ONSET
YEARS
TRIGGERING FACTOR IF NOTED
COLD
HEAT
VACCINATION
STRESS
FATIGUE
2/6
DOB / SSN
THORAX
NONE
PAIN
PERICARDITIS (Detected abnormal
amount of pericardial fluid)
PLEURITIS (Detected fluid collection in
pleural cavity)
ABDOMEN
NONE
PAIN
VOMITING
DIARRHEA
HEPATOMEGALY
SPLENOMEGALY
SKELETAL FINDINGS
NONE
MYALGIA
ARTHRALGIA
ARTHRITIS
DEFORMING ARTHROPATHY
SKIN/MUCOUS MEMBRANE: DURING ATTACK
NONE
PSEUDOERYSIPELAS
URTICARIA
APHTOSIS (BUCCAL/GENITAL)
PHARYNGITIS
OTHER / SPECIFY
SKIN/MUCOUS MEMBRANE: CHRONIC
ACNE
PYODERMA GANGRENOSUM
OTHER / SPECIFY
EYE
NONE
CONJUNCTIVITIS
UVEITIS
PAPILLITIS
CENTRAL NERVOUS SYSTEM
NONE
MENINGITIS
DEAFNESS
MENTAL RETARDATION
KIDNEY
NONE
PROTEINURIA
AMYLOIDOSIS
3/6
DOB / SSN
OTHER SYMPTOMS ASSOCIATED WITH ATTACKS (ADENOPATHY, SCROTITIS, GROWTH RETARDATION)
LABORATORY FINDINGS DURING ATTACKS
CRP
ESR
MG/L
LEUCOCYTE COUNT
MM/H
109/L
OTHER (SPECIFY E.G. URINE LEVEL OF MEVALONIC ACID, S-IGD, S-AMYLOID A ETC)
TREATMENTS
NONE
COLCHICINE
ANTI-IL-1β AGENTS
ANTI-TNF-α AGENTS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
CORTICOSTEROIDS
STATINS
G-CSF
OTHER MEDICATIONS / SPECIFY
OTHER CLINICAL FEATURES OF PATIENT / FAMILY? OTHER DISEASES IN THE FAMILY? OTHER RELEVANT INFORMATION FOR
THE GENETICISTS?
4/6
DOB / SSN
ORDER SUMMARY
PERIODIC FEVER PANEL
The price for the purchased services is presented at the Blueprint Genetics website (www.blueprintgenetics.com/pricing). Custom pricing applies if separately agreed between your institution and Blueprint Genetics.
To complete the purchase, please send 5 ml of EDTA blood (3 ml for an infant), saliva or a minimum 10 µg of purified DNA along with this order
form and the informed consent to this address:
BLUEPRINT GENETICS OY
SAMPLES
TUKHOLMANKATU 8, BIOMEDICUM 2U
00290 HELSINKI
FINLAND
For ordering instructions with more details, please visit http://www.blueprintgenetics.com/how-to-order
Delivery of results by regular mail (€20 extra charge). Results will be available with no extra charge in our online reporting system at
nucleus.blueprintgenetics.com (you will receive personal login and password after the purchase is confirmed).
For EDTA blood samples we charge €50 extra for the isolation of DNA.
The patient has signed the informed consent and either allowed or denied permission to use the sample for research.
I have read and understood the General Terms of Service available online at www.blueprintgenetics.com/general-terms and I am duly
authorized by the Customer organization to order Services from Blueprint Genetics.
DATE / PLACE
PHONE NUMBER
NAME
SIGNATURE
Blueprint Genetics Oy
Tukholmankatu 8, Biomedicum 2U
00290 Helsinki, Finland
+358 40 2511 372
VAT number FI22307900
Bank name Nordea Pankki Oyj
IBAN FI97 1745 3000 0741 63
BIC NDEAFIHH
5/6
DOB / SSN
PATIENT’S INFORMED CONSENT TO THE RESEARCH USE AND STORAGE OF THE SAMPLE
IN THE RESEARCH LABORATORY
By signing this Informed Consent, I certify that the information below has been explained to me concerning the use of the DNA sample taken for
gene diagnostic purposes in research into hereditary Mendelian diseases and the efforts to improve the diagnostics and treatment of said diseases. Furthermore, I give my consent to the storage of the DNA sample in the diagnostic laboratory of Blueprint Genetics.
The research data concerning me will be treated as confidential information and coded in such a way that my identity cannot be discovered
without the key code in the possession of the Blueprint Genetics research physician. Where necessary, such coded research data may also be
processed within or outside the European Union and released for use by another research group or a company participating in the study. I hereby
give my consent to the use of the aforementioned research data in said study.
I understand that my consent to the research use of the sample taken for diagnostic purposes is voluntary and that I may cancel this Informed
Consent and withdraw my participation at any time prior to the completion of the study. I am also aware that the data collected up to the date of
my withdrawal will be used as part of the research material. However, my refusal to take part in or withdraw from the research project will not in any
way affect my further treatment.
For consent forms in other languages: http://blueprintgenetics.com/Informed-Consent-Forms
I give my consent to the research use and storage of the sample.
I do not give my consent to the research use and storage of the sample.
DATE
PLACE
NAME
SIGNATURE
Blueprint Genetics Oy
Tukholmankatu 8, Biomedicum 2U
00290 Helsinki, Finland
+358 40 2511 372
VAT number FI22307900
Bank name Nordea Pankki Oyj
IBAN FI97 1745 3000 0741 63
BIC NDEAFIHH
6/6